Chicago Recovery Alliance

Case Study

Chicago, Illinois
Dan Bigg from CRA talks about how the first take-home naloxone program in the US began.

CRAChicago Recovery Alliance started harm reduction (HR) outreach in January of 1992 and, through respectful collaboration with people injecting, has grown to become one of the larger HR programs in the world to date. Starting in a state where it was illegal to purchase or possess a syringe without a prescription our work’s research component exempted us and our participants from the laws against syringe and other injection equipment prohibitions.  As we grew, we have met regularly and formally with our participants in what we call Community Advisory Groups (CAG) — composed of a diverse group of people injecting in a geographically limited area–paying people for their expertise and having a good meal at each CAG meeting.  CAGs have always informed both the initiation of and ongoing feedback about our work. If CRA owes anything to its successes it is listening to the feedback given by CAGs!  As our participants reported other needs and interests we responded similarly — viral hepatitis prevention as the ‘gold-standard’ of safer injection including integrating HAV/HBV vaccination into our work and addressing opiate-related overdose prevention. As early as 1995, CRA made our first t-shirt that had a list of harm reduction options on the back, including: “Keep Narcan Around.”

It was May 4, 1996 and one of our founders, John Szyler (who had created our philosophical touchstone: any positive change) died of a heroin overdose.  He left us to not only grieve his loss, but also to use his death to motivate — you guessed it — another positive change in helping people prevent overdose by teaching about it and making naloxone, the decades proven opiate overdose antidote available to our participants.  In the fall of 1996, after sadness turned to desire for action, myself and some MD friends started naloxone training and distribution to select CRA participants. Overdose was, and is, the number one cause of premature death among our participants and people were delighted with having this resource available to them.  For those who had heard about naloxone, it was generally as kindly as garlic might be to a vampire as most experiences were abuses of the drug at the hand of an emergency medical provider who shot 2mg IV into a person who overdoses, then fought with them as they exploded out of the emergency room or ambulance in withdrawal. Following HR practice we sought out medical help which valued and respected life and human rights. Shawn DeLater, an emergency room physician and Sarz Maxwell, an addictionologist, were our first medical care providers ready and willing to put a healthy, lifesaving touch to reversing opiate-related overdose with effective and humane intervention.  From 1997 to 1999, our program expanded slowly and steadily in Chicago, and at our insistence, the Drug Policy Alliance holds the first Opiate OD Conference in Seattle with international presenters in early 2000.

In January 2001, CRA rolled out its first OD training for all staff and interested volunteers and participants and incorporated naloxone distribution to all sites and contact points CRA operates.  At this time, we also posted materials on our website for any other program to use. Through spreading the word through the Harm Reduction community about the effectiveness of naloxone distribution, by the late 1990s and early 2000s other programs in the US began to start distributing naloxone.

One consistent hurdle in development of our program was we first tried to err on the side of caution and provide a lengthy training to participants…After the program was going for a while we realized that getting good OD info (focus on maintaining airway and breathing) and naloxone to people in sufficient economy was essential and also that we slowly distilled the essential information down to a few essential points which we called SCARE ME:

Stimulation: Does the person respond to painful stimulation like a knuckle rub to sternum or upper lips?  If no, this is an overdose needing attention.
Call 911: While it is true that a group of people actively incarcerated by police might hesitate to call for help it was important to do if possible.
Airway: Is the person’s airway unobstructed and are you able to breath for them?  Surviving an opiate OD is all about having a clear airway and breath!
Rescue Breathing: Provide rescue breathing for the person as this can save a life if all else fails!
Evaluate the Situation: How is the breathing coming along?  Do you need and have naloxone nearby?  Is it worth stopping the breathing to get it?

Muscular Injection: Inject 1-2cc of naloxone into the person’s shoulder, butt or thigh muscle using 1-1.5 inch needle. Resume rescue breaths.
Evaluate again: Naloxone takes 3-5 minutes to work.  Keep up rescue breathing.  Give another dose of naloxone if no response in five minutes.

In 2010, through collaboration with the AIDS Foundation of Chicago and other HR programs in Illinois we came to enact a new law supporting effective OD prevention work in our state (20 ILCS 301/5-23) which exempts both prescribers of naloxone and lay persons who try to revive a person with naloxone. Since then, many other programs in IL have started providing naloxone.

Our approach is based on forming harm reduction relationships with participants; listening for needs/interests and acting accordingly; and consistently providing as many options for positive change as possible. Through August 2011 we have provided 22,010 overdose prevention encounters and received from our participants 2,720 reports of peer opiate-related overdose reversal!

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